New Directions in Health Systems Research

The ideas of resilience and responsiveness are central to understanding how health systems can sustain progress in health development and poverty reduction. Resilient health systems withstand shocks and adapt to changing needs, delivering necessary services without placing a financial burden on poor households. Responsive health systems promote dignity in care while recognising differences in need among population groups.

Resilient and responsive health systems require a strong foundation of fairly distributed financial and human resources; systems that support equitable, effective and efficient resource mobilisation and service delivery; and governance approaches that enable and sustain these activities by promoting reflective learning and accountability.

KEY THEMES

Financing Research focuses on how best to finance universal health coverage in low and middle-income countries by looking at how to establish progressive financing systems in different settings and understanding which features of pooling and purchasing arrangements promote health equity and financial protection for the poor.

Workforce Research in this area will identify effective, practical interventions to improve health worker retention in rural areas and public sector services by evaluating the importance of different incentives in influencing behaviour and job location choices and assessing the extent and impact of health worker training by private institutions.

Governance Research focuses on decision-making across the health system - including leadership - and explores how accountability can be strengthened to support improved responsiveness in health systems.

This ambitious programme of research has been developed through stakeholder engagement to ensure that the research questions reflect priority needs of policy makers and health sector managers. Through a continuous process of reflection and discussion we aim to ensure that our questions and methods reflect best practice and remain at the forefront of health policy and systems research. Calls for universal health coverage have prompted a reassessment of health financing systems and the degree to which they promote financial protection and access to needed care in developing countries. RESYST research on health care financing focuses on three critical elements of the universal health care agenda: mobilizing resources (or expanding “fiscal space”) for health; providing cover for the informal sector; and using strategic purchasing to ensure access to efficient and effective health services.

Resilient and responsive health systems require a stable funding base that relies increasingly on domestic – rather than external – resources and is replenished through progressive means. Extending coverage to the entire population requires a critical assessment of the options for expanding the fiscal space for health. Previous efforts to raise money for health from user fees caused financial hardship for many while deterring others completely – particularly among the poor - thereby decreasing the responsiveness of the health care system to population needs. Current debates centre on the relative merits of contributory vs. non-contributory financing mechanisms, and the role that each has to play in building a universal coverage system. Contextual factors and path dependence are clearly important, including the size and nature of the informal sector – those from whom it is difficult or costly to collect premia either because they are too poor, or are in informal employment. In many settings it may be more practical and cost effective to expand the fiscal space and rely to a greater extent on tax funding. Yet many low- and middle-income countries are reluctant to do this arguing that it is impossible to raise more money through taxation. A few countries have nonetheless demonstrated that fiscal space can be improved through strengthening the tax base and administrative system, generating additional resources to support universal coverage. More needs to be learned from these experiences.

Of course, increasing domestic resources is only part of the challenge. Finance ministries need to be persuaded to allocate more resources to health. They need to be convinced of the economic and social benefits of spending on health services and satisfied that the health sector is able to absorb additional funding and to spend it efficiently and equitably. Of central importance here is the role of strategic purchasing to promote equity and quality in service provision and to contain costs. Purchasing involves a range of functions from determining the services that will be provided to meet population health needs through identifying the providers capable of delivering effective and efficient services in an equitable manner. But it doesn’t end there. Purchasing also refers to the deployment of provider payment mechanisms to ensure efficient use of resources and monitoring the system to ensure that it is performing to a high level. Purchasing is therefore a key tool for realising health system responsiveness and resilience and an important strategy for achieving universal coverage.

Against this backdrop, we seek to contribute to ongoing debates about how best to finance universal health coverage in low and middle-income countries with a particular focus on improving domestic funding and strategic purchasing. Key questions explored under the financing theme include:

- How can progressive financing systems be developed in different settings particularly through increasing domestic public funding?
- What features of purchasing arrangements within health insurance schemes promote financial protection and equity in access to care for the poor?

A critical assessment of purchasing arrangements in a range of RESYST countries will examine the effectiveness of different public and private purchasers in securing needed care for populations while at the same time ensuring financial risk protection and equitable access. We are particularly interested in the governance of these purchasers and their capacity to procure high quality services from a range of cost effective health care providers. Where changes in purchasing arrangements are being introduced we will evaluate these to see how they improve system performance.

For more information on this or any other aspect of our work on financing, please contact Di McIntyre (Diane.McIntyre@uct.ac.za), Jane Chuma (JChuma@kenni-wellcome.org) or Viroj Tangcharoensathien (viroj@ihpp.thaigov.net) According to standard economic theory, rational actors – whether they are individuals, households, organisations or larger units of analysis – seek to maximise economic gains (defined exclusively in financial terms) by choosing between competing options according to market signals. So is it all about the money? Our work on human resources seeks to answer that question by critically evaluating the role of financial incentives in the health sector. We hope this will lead to a more nuanced understanding of health worker preferences and, by extension, practical measures to address the shortfall of resources in this critical area.

We begin by exploring the importance of financial factors in nurses’ career choices and the degree to which they affect decisions to move out of the public sector or to leave rural areas. There is a real lack of data in this area and little is known about the factors that influence health professionals’ job location choices – much less the importance they attach to them – in low and middle income countries. In particular, it is unclear whether and to what extent, financial considerations feature in decisions to leave public sector and rural jobs. Building on a unique longitudinal cohort of more than 350 newly-qualified nurses initiated in South Africa in 2008, this research aims to identify effective interventions to recruit and retain nurses in under-served areas of South Africa and to contribute to policy debates in other settings.

We then move on to investigate the extent of health workforce training by private institutions in Thailand, India, Uganda and Kenya, and the impact this is having on the public provision of health services. While these private actors may complement public production of qualified staff and limit the loss of publicly-trained health professionals to private providers, there are concerns about the rapid expansion of this largely unregulated sector. If these institutions are primarily driven by a profit motive, this may have a negative impact on the quality and costs of training; it may also undermine the values and career aspirations of newly qualified health professionals.

Finally, we consider different remuneration mechanisms and their effect on health workers’ decisions and performance. To what extent are purely financial incentives tempered by other factors, including altruism and intrinsic motivation? With few exceptions, work in this area has been confined to health service delivery in high income countries. Given the growing importance of purchasing activities in the provision of healthcare in low and middle income countries, it is essential to undertake further research on providers’ motivation and their responses to financial and non-financial incentives. Using innovative methods such as discrete choice experiments, we will assess how providers respond to alternative payment mechanisms and how other interventions might mediate these responses. Wherever possible, we aim to study these issues in a real-world setting, building on pilot programmes where new payment mechanisms are effectively introduced. The term governance points to a critical set of health system characteristics and processes – ranging from structures and authorities, to decision-making and policy formulation, to regulatory frameworks and mechanisms designed to ensure accountability and prevent corruption. Evidence shows that strong governance and leadership are essential to resilient and responsive health systems. These are systems that can withstand unexpected shocks and take advantage of opportunities for development; are committed to achieving health and health equity goals; and are able to adapt to the changing needs of their population while undergoing a continuous process of change themselves.

But it is not health systems that take the decisions that matter. People make these decisions. And not only the politicians shaping agendas and launching directives, or the people who work in central policy and planning positions. But also, critically, the people distributed across every health system who provide the decentralised and sustained leadership required to maintain, over time, a focus on local needs and services.

The RESYST governance agenda is contributing to our understanding of health system development by homing in on the micro-practices of leaders at the front line of management and service delivery. It aims to understand their decision-making processes, their professional relationships and the factors that affect how they operate. It will consider how their actions influence accountability outwards, to the community, and upwards, to the policy actors mapping out new paths in health system development. It will explore the innovations developed by front line leaders to better address local needs and concerns, in line with policy goals. As governance is, rightly, a public concern, the work focuses on public sector leadership and decision-making but seeks to locate this within the broader context and spectrum of health system actors where appropriate.

"It’s not health systems that take the decisions that matter. People make these decisions."

Our programme of work is predicated on active engagement with health system decision-makers. Recognising the importance of tacit knowledge, we use collaborative research approaches to co-produce practical, policy relevant lessons. In South Africa and Kenya for example, we are developing district level learning sites. These sites allow us to better understand the inner workings of local health systems by facilitating long-term, flexible engagement between local decision-makers and researchers. In other parts of our programme, manager-researcher teams will develop theories of change around specific policies to strengthen health systems; these will allow us to track and evaluate changes over time. As such, our programme will provide a platform for reflecting on new forms of health policy and systems research and their contribution to the development of the field.

At present the RESYST governance programme is supporting:

- Assessment of routine micro-governance practices at district and sub-district levels together with their impact on policy implementation and primary health care development in Kenya and South Africa;
- Evaluation of the Health Sector Services Fund (HSSF) in Kenya with a particular focus on whether and how the programme facilitates accountability upwards and outwards;
- Development of implementation guidance to support accountability for new funds being made available for Primary Health Care in Nigeria;
- Inquiry into the leadership capabilities of health system managers working in primary health care at sub-district and district level in South Africa and Kenya;
- Implementation, tracking and evaluation of district level experiences with reference to health system development intended to promote universal coverage in Tanzania and South Africa.

Through this programme of work we aim to contribute to a policy-relevant understanding of what supports good governance and distributed leadership and what is required to sustain and strengthen it over time.

For more information on this or any other aspect of our work on governance, please contact Lucy Gilson (Lucy.Gilson@uct.ac.za) or Sassy Molyneux (smolyneux@kemri-wellcome.org)